Tatiossian, Mark 76763C 275 Gatsey Ln.

. (CAMA / ❑ DREDGE & FILL W 76763 B CC) D
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GENERAL PERMIT �Reissuee
Previous permit#❑Modification ❑Complete Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC T � � /
Rules attached.
Applicant NameR ¢1 140 Project Location: County
Address a s Street Address/ State Road/ Lot #(s) SE
City Sta
Phone # (✓ E-Mail
Authorized Agent
Affected ❑ CW �W � A
AEC(s): ❑ OEA ❑ HHF ❑ IH
❑ PWS:
ORW: yes / o PNA yes no
Type of Project/ Activity
Pier (dock) length
Fixed Platform(s) n C!T -IL
Floating Platform(s)
Finger pier(s)
Groin length
number
Bulkhead/ Riprap length
avg distance offshore
max distance offshore
Basin, channel
cubic yards
Boat ramp
Beach Bulldo ing
Other
r
Shoreline Length c/
SAV: not sure yes P.
Moratorium: n/a yes no\
Waiver Attached: yes I no
A building permit may be required by:
( Note Local Planning jurisdiction) p_
Notes/ Special Conditions _��(`
Subdivision pp /
City D ZIP
Phone # (A) River Basin ,
Adj. Wtr. Body Uee-na ma unkn
Closest Maj. Wtr. Body
(Scale:
Gt A n 1 Y ❑ See note on back regarding River Basin rules.
r
s LaAA) v
A or Applicant Printed Name
Signature ** Please read compliance statement on back of permit j,;
Application Fee(s) Check #
�4 COMM,
1l
PermitOfficer's Prin ame
Signat e C
Iss ng Dat� 'txpiratlon Date